OFFICE OF INSPECTOR GENERAL

TEXAS HEALTH & HUMAN SERVICES COMMISSION

OFFICE OF INSPECTOR GENERAL

REVIEW OF RESTORATIVE PROGRAMS

SEPTEMBER 22, 2014

OFFICE OF INSPECTOR GENERAL REVIEW

RESTORATIVE PROGRAMS

TOILETING PROGRAMS

TURNING/REPOSITIONING PROGRAMS

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Restorative nursing program refers to nursing interventions that promote the resident’s ability to adapt and adjust to living as independently andsafely as possible. This concept actively focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning.

The following criteria for restorative nursing programs must be met in order to code 00500 per the RAI:

• Measureable objective and interventions must be documented in the care plan and in the medical record. If a restorative nuisingprogram is in place when a care plan is being revised, it is appropriate to reassess progress, goals, and duration/frequency as part ofthe care planning process. Good clinical practice would indicate that the results of this reassessment should be documented in theresident’s medical record.

• Evidence of periodic evaluation by the licensed nurse must be present in the resident’s medical record. When not contraindicated bystate practice act provisions, a progress note written by the restorative aide and countersigned by a licensed nurse is sufficient todocument the restorative nursing program once the purpose and objectives of treatment have been established.

• Nursing assistants/aides must be trained in the techniques that promote resident involvement in the activity.

• A registered nurse or a licensed practical (vocational) nurse must supervise the activities in a restorative nursing program. Sometimes,under licensed nurse supervision, other staff and volunteers will be assigned to work with specific residents. Restorative nursing doesnot require a physician’s order. Nursing homes may elect to have licensed rehabilitation professionals perform repetitive exercises andother maintenance treatments or to supervise aides performing these maintenance services. In situations where such services do notactually require the involvement of a qualified therapist, the services may not be coded as therapy in item 00400, Therapies, becausethe specific interventions are considered restorative nursing services (see item 00400, Therapies). The therapist’s time actuallyproviding the maintenance service can be included when counting restorative nursing minutes, Although therapists may participate,members of the nursing staff are still responsible for overall coordination and supervision of restorative nursing programs.

(There are no changes in the RAI version 1.12 released 9/17/2014)

Per the RAI, there are 10 (ten) identified Restorative areas.

00500A, Range of Motion (Passive): Code provision of passive movements in order to maintain flexibility and useful motion in the joints of thebody. These exercises must be individualized to the resident’s needs, planned, monitored, evaluated and documented in the resident’s medicalrecord.

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005008, Range of Motion (Active): Code exercises performed by the resident, with cueing, supervision, or physical assist by staff that areindividualized to the resident’s needs, planned, monitored, evaluated, and documented in the resident’s medical record. Include active ROM andactive-assisted ROM.

(For both active and passive range of motion: movement by a resident that is incidental to dressing, bathing, etc., does not count as part of aformal restorative nursing program. For inclusion in this section, active or passive range of motion must be a component of an individualizedprogram that is planned, monitored, evaluated, and documented in the resident’s medical record. Range of motion should be delivered by staffwho are trained in the procedures).

OOSOOC, Splint or Brace Assistance: Code provision of (1) verbal and physical guidance and direction that teaches the resident how to apply,manipulate, and care for a brace or splint; or (2) a scheduled program of applying and removing a splint or brace. These sessions areindividualized to the resident’s needs, planned, monitored, evaluated, and documented in the resident’s medical record.

(For splint or brace assistance: assess the resident’s skin and circulation under the device, and reposition the limb in correct alignment),

Training and Skill Practice: Activities including repetition, physical or verbal cueing. and/or task segmentation provided by any staff memberunder the supervision of a licensed nurse.

005000, Bed Mobility: Code activities provided to improve or maintain the resident’s self-performance in moving to and from a lying position,turning side to side and positioning himself or herself in bed. These activities are individualized to the resident’s needs, planned, monitored,evaluated, and documented in the resident’s medical record.

00500E, Transfer: Code activities provided to improve or maintain the resident’s self-performance in moving between surtaces or planes eitherwith or without assistive devices. These activities are individualized to the resident’s needs, planned, monitored, evaluated, and documented in theresident’s medical record.

00500F, Walking: Code activities provided to improve or maintain the resident’s self-performance in walking, with or without assistive devices,These activities are individualized to the resident’s needs, planned, monitored, evaluated, and documented in the resident’s medical record.

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00500G, Dressing andlor Grooming: Code activities provided to improve or maintain the resident’s self-performance in dressing andundressing, bathing and washing, and performing other personal hygiene tasks. These activities are individualized to the resident’s needs,planned, monitored, evaluated, and documented in the resident’s medical record.

0050011, Eating and/or Swallowing: Code activities provided to improve or maintain the resident’s self-performance in feeding oneself food andfluids, or activities used to improve or maintain the resident’s ability to ingest nutrition and hydration by mouth. These activities are individualized tothe resident’s needs, planned, monitored, evaluated, and documented in the resident’s medical record.

005001, Amputationl Prosthesis Care: Code activities provided to improve or maintain the resident’s self-performance in putting on andremoving a prosthesis, caring for the prosthesis, and providing appropriate hygiene at the site where the prosthesis attaches to the body (e.g., legstump or eye socket). Dentures are not considered to be prostheses for coding this item. These activities are individualized to the resident’sneeds, planned, monitored, evaluated, and documented in the resident’s medical record.

00500J, Communication: Code activities provided to improve or maintain the residents self-performance in functional communication skills orassisting the resident in using residual communication skills and adaptive devices. These activities are individualized to the resident’s needs,planned, monitored, evaluated, and documented in the resident’s medical record.

(The time provided for items 00500A-J must be coded separately, in time blocks of 15 minutes or more.)

TAC: §371.21 2(c)(1 6)(C) For Nursing Rehabilitation/Restorative Care, code between zero and seven the number of days on which the technique,procedure, or activity was practiced for a total of at least 15 minutes during each 24-hour period during the look back period. This includes nursinginterventions that assist or promote the recipient’s ability to attain his or her maximum functional potential, but does not include procedures ortechniques carried out by or under the direction of a qualified therapist(s), as identified in the Special Treatments, Procedures, and Programssection of the MDS. The nursing rehabilitation and/or restorative care must meet all of the following additional criteria. The look back period foritems described in this subparagraph is seven days.

(i) Measurable objectives and interventions must be documented in the care plan and in the clinical record as observed during the look backperiod.

(n) Evidence of periodic evaluation by licensed nurse must be present in the clinical record.

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(iii) Nurse assistants/aides must be trained in the techniques that promote recipient involvement in the activity.

(iv) The activities must be carried out or supervised by identified members of the nursing staff. There must be documentation, includingminutes, in the chnical record for the nursing rehabilitation and/or restorative care program as observed during the look back period. Thisdoes not include groups with more than four recipients per identified supervising helper or caregiver. There must be documented evidencethat services provided in a group setting were provided to a group of four or less.

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Note: Toileting programs are not listed as restorative programs but are counted in the RUG calculation.

Toileting (or trial toileting) programs refer to a specific approach that is organized, planned, documented, monitored, and evaluated that isconsistent with the nursing home’s policies and procedures and current standards of practice. A toileting program does not refer to:

• simply tracking continence status,• changing pads or wet garments, and• random assistance with toileting or hygiene.

BLADDER REHABILITATION! BLADDER RETRAINING

• A behavioral technique that requires the resident to resist or inhibit the sensation of urgency (the strong desire to urinate), to postpone ordelay voiding, and to urinate according to a timetable rather than to the urge to void.

PROMPTED VOIDING

• Prompted voiding includes (1) regular monitoring with encouragement to report continence status, (2) using a schedule and prompting theresident to toilet, and (3) praise and positive feedback when the resident is continent and attempts to toilet,

HABIT TRAINING! SCHEDULED VOIDING

• A behavior technique that calls for scheduled toileting at regular intervals on a planned basis to match the resident’s voiding habits orneeds.

Look for documentation in the medical record showing that the following three requirements have been met:

• implementation of an individualized, resident’specific toileting program that was based on an assessment of the resident’s uniquevoiding pattern

• evidence that the individualized program was communicated to staff and the resident (as appropriate) verbally and through a care plan,flow records, and a written report

• notations of the resident’s response to the toileting program and subsequent evaluations, as needed

(Guidance for developing a toileting program may be obtained from sources found in Appendix C of the RAI)

(There are no changes in the RAI version 1.12 released 911 7/2014)

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TAO: §371.212(c)(5) Oontinence Appliances and Programs. The look back period for items described in this paragraph is 14 days.

(A) For Scheduled Toileting Plan, check if recipient is on any scheduled toileting program. The documentation must include a plan for bowel and/orbladder elimination whereby staff members at scheduled times each day either take the recipient to the toilet, give the recipient a urinal, or remindthe recipient to go to the toilet. This includes bowel habit training and/or prompted voiding, but does not include changing wet garments. A‘program refers to a specific approach that is organized, planned, documented, monitored and evaluated. The recipient’s toileting schedule mustbe in a place where it is clearly communicated, available to and easily accessible to all stall. The care plan must indicate the recipient is on aroutine toileting schedule.

(B) For Bladder Retraining Program, check if recipient is on any bladder retraining program that is a retraining program to teach the recipient toconsciously delay urinating or to resist the urge to urinate. The care plan must include individualized goals and approaches that is organized,planned, documented monitored, and evaluated.

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Another “program” affecting RUG calculations is found in Section M.

M1200C Turning/Repositioning Program: Includes a consistent program for changing the resident’s position and realigning the body. “Program”is defined as a specific approach that is organized, planned, documented, monitored, and evaluated based on an assessment of the resident’sneeds.

• The turning/repositioning program is specific as to the approaches for changing the resident’s position and realigning the body. The programshould specify the intervention (e.g., reposition on side, pillows between knees) and frequency (e.g., every 2 hours).

• Progress notes, assessments, and other documentation (as dictated by facility policy) should support that the turning/repositioning program ismonitored and reassessed to determine the effectiveness of the intervention.

(There are no changes in the RAI version 1.12 released 9/17/2014)

TAC: §371.212(c)(12)(C) Turning/repositioning program, to include a continuous, consistent program for changing the recipient’s position andrealigning the body. There must be a specific approach that is organized, planned, documented, monitored, and evaluated;

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Resident Name: Room: Month and ‘i’ear of Service

NURSING RESTOR.A VE CARE PROGRAM EX ‘

Jcensed StaWnaWre

SECTION I - PLAN OF CAREKnioretive Tech,o que {MOS S.cnoo P)j

a/b ROM Passive 3/or Act,ve

C Spiint or brace AssisLanc

WI Bed Mobikly &;or Wallong Training

C Trans(e Tiainrng

9 Dressng or Grooming naming

h Eatng or Swallowing training

I ArnputatiomvProsthesms Care

Communication Training

k Toileting Prograin/Wadier Training

The Goal must be 15 minutes or morefor 7 days per week

Group activities are limited to fourResidents or less per Team Member

DATE PLAN INITIATEDGOAL

iUsi&.ntwLWca1nplav.’4DL’ wtdvU.nLtect gctffau&tetce’

gdntwj4,nave’cthota

APPROACH WITH FREQUENCY

1 Regde.nt will’pe4cxnn vj/evav.t2-ADLs’wch LL.yuc ,wt.on4je’t et p qd 15

2 R€aL&vtt wdL waV./wkd w tffpen’uon’jd x- bc) fr’t ‘ 15 .nate.

DATENURSE SIGNATURE

NOTES

— Monthly Review -— Key

A. Is the Plan of Care Appropriate? N

B. Aie Changes to the Program Recommended?

Are Changes Recommended to the Goats? Y

Ate Changes Recommended to the Appfoaches2 Y

It yes to B, UPDATE NEXT MONTftS SECTION - PLAN OF CARE

WITH THE CHANGES.

C. Continue Program?

Discontinue Program?

Independent - No help or staff oversight (no mouth, hands. or eye.)

Supervision - Oveis.ght, encouragement, or cueing provided

(mouth eyes. no hands)

Limited Assistance- Resident highly involved in activity.

received physical help in guided maneuvenng of knits or other non

weight-tearing assistance (hands used for setup but no itt-ny w

weight tanng)

Extensive Assistance -While the resident pci-forms part of activity

eight-tearing support is provided iitcoy or .r.eighl be&imrg

jnivpari of tie flsi.Jtnli

DateIota! Dependence - Fuii staff performance of the activity

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Example #1

Goal #1 is identified as related to ‘.Q” which is identified in the grid as Dressing or Grooming Training”. The actual goal states will complete ADLswith limited assistance. There is no description of which ADLs.

RAI: ‘Code activities provided to improve or maintain the resident’s self-performance in dressing and undressing, bathing and washing, andperforming other personal hygiene tasks. These activities are individualized to the resident’s needs, planned, monitored, evaluated, anddocumented in the resident’s medical record.”

Goal #2 is related to Walking Training- The goal states will move about environment with supervision.

What environment, in room or throughout facility? How will the resident move? Walking or in a wheelchair? How can you measure “supervision”?

RAI: “Code activities provided to improve or maintain the resident’s self-performance in walking, with or without assistive devices. These activitiesare individualized to the resident’s needs, planned, monitored, evaluated, and documented in the resident’s medical record.”

Per RAI, page 0-33, the time provided for items 00500A-J must be coded separately, in time blocks of 15 minutes or more.

Review:

1. Goals #1 and #2 have no measurable objectives. The goals are not individualized to the resident.

Example of a measurable objective: Mrs. Jones will comb her hair and apply her lipstick daily with verbal encouragement.

Example ala measurable intervention: Mrs. Jones will do Range of Motion exercises 15 minutes daily to fingers, wrists andelbows to maintain joint flexibility for grooming.

2. This example does not have a document recording the time spent on each goal. Since there are two techniques addressed, theexpectation is the documentation would demonstrate the time and # of days for each technique.

3. The documentation would clearly identify the staff providing the services.

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4, The key in the upper left corner refers to Section P3 of the MDS and combines restorative techniques making it difficult to properly codethe MDS. Reviewing MDS 3.0 with facility documentation which uses terminology from MDS 2.0 put the reviewer and facility in possiblerisk situations.

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NURSING RESTORATIVE CARE PROGRAM

Resident Name: Room: Month and Year of Service

I SECTION I - PLAN OF CARE R4TEPMA/IMJTI,4TW

_____________

jrstorative Technique (MIDS Section P GOALa/b ROM Passive &Jor Active JtrenjithJcs’Jce%a’tltØ/ wabsncrea-se’AEa 4tnprcn/e-transfrwy

C Splint or Grace Assistance and’ROA/dif Bed Mobility &ior Walking Training wU actwe% prtCcIpate- £n- Mobility by a.t&ndaaon- w/WcWcer

Transfer Training WCtJvSB4S4 I atae-255O ftg Dressing or Grooming Training

h Eating or Swallowing Training

Amputation/Prosthesis Care APPRO4CH WITh FREQUUNCYCommunication Training

k Toileung Program/Bladder Training I wt2pttv ewtro rccaezqd’jfr AROAI, CA/A. to-aijiota- neea’ethThe Goal must be 15 minutes or more for7 days per week

Group activities are limited to four 2 -wdtwaLc-astntwa..Lerto-Disu.ng-Rocrn-i€ir2 inecdspercLzii u’itksr&ss4ste/’Residents or less per Team Member CMVi ars-neede&

NURSE SIGNATURE DATE

NOTES:

‘EA. Is the Plan ol care Appropnale? ‘V N Independent - No help or staff oversight (no mouth, hands. ui eyes)Ii Are Changes to the Program Recommended? Y N Supewision - Oversight, encouragement, or cueing provided

Are Changes Recommended to the Goals? ‘/ N (mouth, eyes, no hands)Are Changes Recommended to the Approache V N Limited Assistance - Resident highly involved in activity,

If yes to B, UPDATE NEXT MONTh’S SECTION 1- PLAN OF received physical help in guided maneuvering of limbs or other nonWITH THE CHANGES. weight-beaiing assistance (hands used for set-up but no idling or

C. Continue Program? V N weight bearing)Discontinue Program? Y N Extensive Assistance -While the resident pedorms pail of activity

weight-bearing support is provided (lifting or weight hearingany part of the resident)

a -‘ ae:sus Licensed Staff Signature 1-te Date Total Dependence - Full staff perloimance at the activity

Resident Name: Room Number Month and Year of Plan

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Example #2

Goal#1: Relates to two restorative techniques: strength and flexibility will increase to improve transfers and ROM. How will you measure anincrease, define baseline? How do you measure an ‘improvement”, against a baseline?

Example of a measureable objective: Mrs. Jones will increase her performance during transfers from needing limited assistance toneeding only supervision.

Goal #2: This goal could be accepted, however, SBA and SGA are therapy abbreviations and are not defined in the key. A restorative program isa nursing program and should use nursing terms.

Example rewording of Goal #2: Mrs. Jones will maintain the ability to walk 25-50 daily using a walker with limited assistance from staff.

1. This example does not have a document recording the time spent on each goal. Since there are three techniques addressed, theexpectation is the documentation would demonstrate the time and # of days for each technique. Per RAI, page 0-33, the time provided foritems 00500A-J must be coded separately, in time blocks of 15 minUes or more.

2. The documentation would clearly identify the staff providing the services.

3. The key in the upper left corner refers to Section P3 of the MDS and combines restorative techniques making it difficult to properly codethe MDS. Reviewing MDS 3.0 with facility documentation which uses terminology from MOS 2.0 put the reviewer and facility in possiblerisk situations.

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Resident Name: Room: Month and Year of Service

NURSING RESTOI? ‘VE CARE PROGHAM z

Monthly Review

A. Is The Pan of Care Appropnate? V N

B Ase Changes to Inc Program Recommenced? V N

A:e Changes Remrnended to the Goals? V N

Are Changes Remmended to the Approaches? V N

If yes to B, UPDATE NEXT MONTHS SECTION I - PLAN OF CARL

WITH THE CHANGES.

C. Continue Program?

________

Disconunue Program?

Key

Independent . No help or stall oversight (no mouth, hands. or eyes)

Supervision - Overs.ght. ericouragemerl. UI CUCfl9 piovidi

(mouth, eyes, no hands)

Lim,ted Asststance. Resident highly livolved iii activity.

received physical help in guided maneuvering of (in us or other non

weignt bearing assistance (hands used for set-up but rio lifting or

weight beating)

Extensive Assistance -Wni’.e the resident perloinis purl of acivity

weight-bearing support is piovitled (Iiltng or weight beai.r.g

any part o1 the resident)

Tots] Dependence Full staff performance at the act:vity

SECTION I - PLAN OF CAREReslor.ii.e Teervuque thUS SeoTon P1)

a/b ROM Passive War Active

C Splint or Brace Asstaiice

d/1 Bed Mobitty &/or Walking Trainng

e Transfer Training

9 Dressing or Grooming Training

h Eating or Swallowing Training

I Amputation/Prosthesis Care

Communication Training

k Toileting Program/Bladder Training

The Goal must be 15 minutes or morefor 7 days per week

Group activities are limited to fourResidents or less per Team Member

DATE PLAN INITIATEDGOAL

Re’sictevt.t wLa c tpLete4DL’ w.tk qfk1ptrvtswYv

‘Rasi4ent wdl’ be’ free’ of incantttwmt epioLbs

flfli ‘j drfl5’44üc4’

APPROACH WITH FREQUENCY

1 i&cLet’.t wcUtpe4orn’v mcrnCnLJ/e4ianüig’4DL’- wth cpe4’vtston’E .wt vp qc& x’ 15 vnLnati*)C

2 Uasid&nt wca lxwtLapate’ £ntWe”’rocyca*v bqbre a-nd’ afte-r neaL- Lcd, xi 15 ntc.utte4-

3), -:ii a41o_& -‘,A4,t -g2a.-Ltq ,C ,tcpa.toc4 Y

i-4-oa.’in ‘4)a4-c-1.j €Po 7ict

DATENURSE SIGNATURE

NOTES

Rensed OdYidifl

rYN

N

Licensed Stat) Signature Title Date

‘4

Example #3

This example contains three goals, each for a different technique with ditlerent requirements.

Goal #1, per the provided key, refers to dressing and grooming. Per the HAL code activities are provided to improve or maintain the resident’sself-performance in dressing and undressing, bathing and washing, and performing other personal hygiene tasks. These activities areindividualized to the resident’s needs, planned, monitored, evaluated, and documented in the resident’s medical record. As written, this goal is notmeasurable, not individualized, and does not address a specific ADL.

Example of a measurable objective: Mr. Jones will shave himself daily with set up assistance only from staff.

Goal #2 relates to toileting which has specific requirements. There is no documentation to support that the resident’s “toileting program” meets therequirements of the HAl.

Per HAl, page H-5, “look for documentation in the medical record showing that the following three requirements have been met:.implementation of an individualized, resident-specific toileting program that was based on an assessment of the resident’s unique

voiding pattern.evidence that the individualized program was communicated to staff and the resident (as appropriate) verbally and through a care plan,

flow records, and a written report.notations of the resident’s response to the toileting program and subsequent evaluations, as needed”

Goal #3 is to “maintain ambulatory status”...What ambulatory status is to be maintained? Does resident use an assistive device to walk? Cane,walker, wheelchair? How far is the resident able to ambulate?

Example of a measurable objective for ambulation: Mr. Jones will ambulate from his room to and from the dining room using a walkerdaily for the noon meal with verbal cueing from staff,

1. This example does not have a document recording the time spent on each goal. Since there are three techniques addressed, theexpectation is the documentation would demonstrate the time and number of days for each technique. Per RAI, page 0-33, the timeprovided for items 00500A-J must be coded separately, in time blocks of 15 minutes or more.

2. The documentation would clearly identify the staff providing the services.

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3. The key in the upper left corner refers to Section P3 of the MDS and combines restorative techniques making it difficult to properly codethe MDS. Reviewing MDS 3.0 with facility documentation which uses terminology from MDS 2.0 put the reviewer and facility In possiblerisk situations.

16

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Example #4

This example demonstrates three goals and three techniques, ambulation, spiint’brace. and transfers. Please note the Nursing RestorativeProgram” applies to the discipline of PT. Approach #1 is the same as Goal #1. Per RAI, page 0-33, the time provided for items 00500A-J must becoded separately, in time blocks of 15 minutes or more.

The reviewer is unable to determine which approach goes with which technique for coding the MDS. It appears all approaches go with alltechniques and are unable to determine if the time requirement is met for all three programs.

Goal #1 would be measurable for walking and could suffice as a measurable intervention. The requirements for splint/brace assistance are notmet.

Goal #2 and #3 are the same and address transfers.

Example of a measurable objective: Sam will maintain lower extremity strength to transfer safely from bed to standing positionindependently, The exercise approaches are measurable for this goal.

1. This example does have a document recording the time spent on each goal. Since there are three techniques addressed, the expectationis the documentation would demonstrate the time and # of days for each technique which cannot be deciphered.

2. The documentation did clearly identify the staff providing the services before de-identification.

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Example #5

Neither goal nor approach are measurable and this would not be acceptable documentation for a restorative program.

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